Let's Start by Treating Gun Violence as Public Health Issue

Originally published in AAFP Fresh Perspectives on February 21, 2018

I went to see Hamilton on Broadway, and it was spectacular. If you have the opportunity, go see it. It made me so proud to be a citizen of this complex, complicated and historically entangled American experiment.

In the second act, James Madison, a Federalist but ardent states' rights advocate, turns to Thomas Jefferson, the singular champion for the United States as an agrarian society, and sings, "Thomas, we are engaged in a battle for our nation's very soul. Can you get us out of this mess we're in?"

In real life, Madison proposed the Second Amendment, which was adopted along with the rest of the Bill of Rights in 1791. It was an attempt to appease the anti-Federalist faction, a way to ensure citizens the "security of a free state" with well-regulated militias -- you know, just in case.

The threat of a tyrannical government was real back then, and some argue that it still is. We see it around the world, despots murdering civilians who can't defend themselves. It makes me glad to live in a country where, if I had to, I could defend myself and my family from those trying to take away our rights.

However, last week, instead of watching a Broadway musical, I watched the news in horror. In Parkland, Fla., 14 teenagers and three teachers were ruthlessly gunned down by a former student who, as we now know, had been flagged as a potential threat and expelled from the school. There has been much speculation about his history and his motives, but the bottom line is that 17 people were murdered. Many more were injured. The confessed gunman, Nikolas Cruz, used an AR-15, a semiautomatic "modern" sporting rifle that's cosmetically similar to military weapons.

I spent the remainder of the week trying to wrap my brain around the various responses. These included the usual calls for regulating the buying and selling of guns, increasing support for mental health care, increasing security on campuses, arming teachers, banning violent video games and movies, and reinforcing a culture of "see something/say something." The arguments either focused on taking immediate action (trying to prevent the next massacre) or on effecting long-term systemic change (identifying "the root cause" of violence in the United States). The former faction appeared to show little regard for individual rights as long as it perceived that society as a whole would be safer, while the latter seemed so afraid of government infringement on individual rights that any action to protect the greater good was deemed unacceptable. All in all, the discussion seems like a modern-day version of the great debate, as Madison's character says in the musical, for our nation's soul.

In preparation to write this piece, I read all the comments on gun-related AAFP News articles and blog posts from family physicians, including some from members who thought that even calling gun violence a public health issue was a threat to our civil liberties.

Full disclosure: I think that gun violence, child deaths and suicides by guns are, indeed, a public health issue. I also think that we physicians should get involved in this conversation as an Academy because we care for individuals and families affected by violence in our society.

I'm a young physician, not even a year out of residency. I'm also of the Columbine generation. I was in the sixth grade when the infamous massacre at the Colorado school occurred. I went on summer vacation in May of 1999 and returned in August to new lockdown protocols and bomb threat drills that followed me until my high school graduation. Before then, I had only participated in fire drills and earthquake drills. At the time, I was old enough to comprehend that Columbine had made adults feel helpless, and I was precocious enough to realize that ducking under our desks or hiding in the corner wasn't going to prevent death if an attacker had a semiautomatic weapon.

Students in Parkland, Fla., and other American kids their age are growing up in a post-Columbine society. Lockdown procedures and bomb threat drills are standard. They've never known anything else. But surprisingly, instead of accepting this as their reality, students seem to have a sense of incredulity(www.newyorker.com) at how nothing has been done to stop the proliferation of this sort of violence.

The AAFP has been directed by its policymaking body to take a stand against gun violence. In conjunction with the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American College of Physicians and the American Psychiatric Association, the AAFP recently issued a statement asking the administration to call gun violence a public health epidemic, to start funding appropriate research and to establish "constitutionally appropriate" restrictions.

I know there will be many of you who will applaud this stance, while others will be appalled. Some members may feel unrepresented and unheard and will want to stop the CDC from resuming research on gun violence(www.washingtonpost.com) because they fear it may be used to persecute those who support responsible gun ownership. Responsible gun owners in our own community will feel marginalized and threatened by talk of gun restrictions. Some voices will advocate for more open- and concealed-carry laws. The counterargument will be raised: Guns don't kill people. People kill people.

I hear you. But then what do we do?

If the answer is "improve the people," I'm all for it. I support more mental health services, whether it is counseling, integrated education on coping skills, conflict management, access to medical services or medication if needed. I support introducing curriculum on morality and citizenship and building connection. Limiting work hours, allowing parental leave and more vacation time would also be helpful. From my perspective, however, to move toward such a culture change, we would still need government to be heavily involved in creating and implementing these programs. These interventions are also for the long haul.

What do we do to decrease the rate of gun violence tomorrow? For a start, approach gun violence as a public health issue by focusing on the underlying health causes that influence deaths by guns.

There is a precedent for declaring things that might seem unrelated to hands-on patient care to be public health issues, and we've made changes that have improved health and safety. These include environmental rules to ensure safe drinking water, seatbelt and speed limit laws to decrease fatalities from motor vehicle accidents, and standards to improve workplace health and safety. Harm often comes from individuals, not objects. But by making some strategic, constitutionally appropriate public health changes, we can make gun ownership safer, as well.

Perhaps now is the time we need a Jeffersonian figure to turn to us and ask, "Can you get us out of this mess we're in?"